Healthcare Provider Details

I. General information

NPI: 1104047596
Provider Name (Legal Business Name): WALLACE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8920 WILSHIRE BLVD SUITE 327
BEVERLY HILLS CA
90211-2007
US

IV. Provider business mailing address

8920 WILSHIRE BLVD SUITE 327
BEVERLY HILLS CA
90211-2007
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-8460
  • Fax:
Mailing address:
  • Phone: 310-652-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA49918
License Number StateCA

VIII. Authorized Official

Name: DR. PAUL WESLEY WALLACE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-652-8460